____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
OPIATES AND OPIOIDS The main function of the various drugs in the category of opiates and opioids is to decrease pain by binding to specific receptors in the brain. Drugs in this class that occur naturally and are derived from botanical sources are called opiates , while drugs in this class that are produced synthetically in the laboratory are called opioids . However, the terms “opiates” and “opioids” are often used interchangeably. Almost everyone in society uses drugs in this category as prescribed to treat physical pain such as that following surgery or to avoid pain during a dental procedure. However, some people use these drugs with- out a prescription to get “high” and avoid psychological pain (Freedman, 2023). Opiates and opioids are commonly taken by mouth, smoked, injected, or snorted. This category includes: • Opium and its derivatives such as morphine, heroin, and codeine. • Synthetic drugs such as methadone and buprenorphine (Suboxone or Subutex). • Prescription pain-killing drugs that are frequently abused such as meperidine
Many of the psychotropic effects of alcohol and other drugs occur as a result of the ways in which they interact or interface with the brain’s neurotransmitter systems. Introduction of a drug may effect changes in the concentration of a specific neurotransmitter being released or its reuptake, the transport of the neurotransmitter across the space between neurons, or the sensitivity and density of receptors for the specific neu- rotransmitter substance. Over time, with repeated exposure to a drug, the brain may begin to adapt to the presence of that substance by altering its own production, release, reuptake, or sensitivity to reception. For example, the brain may adjust to the overwhelming surges in neurotransmitters such as dopa- mine by producing less dopamine or by reducing the number of receptors that can receive signals. As a result, dopamine’s effect on the reward circuit of the brain of someone who abuses drugs can become abnormally low, and that person’s ability to experience any pleasure is reduced. Consequently, the person needs to take the substance again and again in an attempt to bring his or her dopamine function back up to normal—which only makes the problem worse (NIDA, 2021c), in a vicious circle that needs to be understood by clinicians. SUBSTANCES OF ABUSE There are many ways of categorizing substances that are com- monly abused today. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5-TR ) offers 10 sepa- rate classes of drugs, listed alphabetically: alcohol, caffeine, can- nabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, tobacco and other unknown substances (American Psychiatric Association [APA], 2023). However, a more useful classification for teaching and clinical purposes is based on the effects of substances on the central nervous system and their impact on the brain (Straussner, 2014). These substances include narcotics or opioids, central nervous system (CNS) depressants, CNS stimulants, psychedelics or hallucinogens, and designer or club drugs, as well as combinations of drugs. Following is a brief discussion of each category of drugs, the drugs that are commonly abused in these categories, and their impact on the individuals abusing them. It is important to note that the drugs within each category (or “drug family”) are chemically similar enough that they can easily substitute for each other. Thus, for example, a person addicted to heroin can easily substitute it with methadone or OxyContin (and vice versa), or a person addicted to alcohol can substitute Valium pills (and vice versa). The brain does not care how the substance is formed, how it is ingested, or its name; it reacts similarly to substances that are chemically similar. This important point will be discussed again in the sections on detoxification from the various substances.
(Demerol), hydromorphone (Dilaudid), fentanyl, propoxyphene (Darvon), phenazocine (Prinadol), diphenoxylate (Lomotil), pentazocine (Talwin), oxycodone (Percodan, Percocet, OxyContin), oxymorphone (Opana), and hydrocodone (Vicodin).
The use of opiates generally tends to have a sedative and tranquilizing effect. However, unlike the users of sedative substances (discussed later), narcotic users do not usually experience poor motor coordination or loss of consciousness. Opiate-using individuals are likely to experience a state of drowsiness and stupor and dwell in daydreaming fantasies. They may also experience nausea and constipation (National Institutes of Health [NIH], 2023). Physical agitation caused by withdrawal and the psychological panic related to anticipation of withdrawal symptoms may result in antisocial behaviors dur- ing drug-seeking activities or actual withdrawal. As indicated previously, there has been a dramatic increase in opioid-related deaths in recent years (Centers for Disease Control and Preven- tion, 2022b). A growing approach to addressing the potentially deadly opioid overdose is the use of naloxone (Narcan), which, within minutes of administration, can undo symptoms of opioid overdose and prevent death resulting from respira- tory failure. Although paramedics have carried naloxone for decades, law enforcement officers in at least 38 states now carry naloxone to quickly respond to opioid overdoses (Bureau of Justice Assistance, 2017). In April 2017, New Mexico became the first state to require all local and state law enforcement agen- cies to provide their officers with the drug (Montoya Bryan, 2017). A movement has arisen with the aim of distributing naloxone to opioid users and teaching them to use it to help fellow addicts who overdose (Brady, 2014; Durando, 2014).
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